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Transgender people, HIV and AIDS

Transgender women in HIV clinic

KEY POINTS:

Transgender people are 49 times more at risk of living with HIV compared to the general population.

Transgender people often face social and legal exclusion, economic vulnerability, and are at an increased risk of experiencing violence. Disempowerment and low self-esteem make transgender women, in particular, less likely or less able, to negotiate condom use.

HIV-related stigma and transphobia create barriers to the access of HIV testing and treatment services by transgender people.

More targeted prevention approaches are needed in combination with increased welfare and employment opportunities to address the specific needs of transgender people.

Transgender people are one of the groups most affected by the HIV epidemic and are 49 times more likely to be living with HIV than the general population.1 Globally, it is estimated that around 19% of transgender women are living with HIV.2 Data from Latin America and the Caribbean show that HIV prevalence is much higher among transgender women sex workers than among non-transgender male and female sex workers.3

There are an estimated 25 million transgender people living around the world.4 The term transgender refers to people whose gender identity and expression are different to social expectations of their biological sex at birth. They may see themselves as male, female, gender non-conformist, or one of a spectrum other genders. Transgender people have diverse sexual orientation and behaviours.

Generally, HIV prevalence among transgender women (people who are assigned male at birth but identify as being women) is higher than transgender men (people who are assigned female at birth but identify as being men). However, very little is known about transgender men and their vulnerability to HIV.

Social, economic and legal exclusion

Across the world transgender people experience high levels of stigma, discrimination, gender-based violenceand abuse, marginalisation and social exclusion. This makes them less likely or able to access services, damages their health and wellbeing, and puts them at higher risk of HIV.

Overlapping social, cultural, legal and economic factors contribute to pushing transgender people to society’s margins. Transgender people are more likely to have dropped out of education, had to move away from family and friends, and faced workplace discrimination, limiting their educational and economic opportunities. They can encounter problems accessing basic goods and services and even public spaces. These challenges are exacerbated by a lack of legal recognition of their gender and the absence of anti-discrimination laws that explicitly include transgender people.5

Sex work

Social exclusion, economic vulnerability and a lack of employment opportunities means that sex work is often the most viable form of income available to transgender people, and a high proportion of transgender people engage in sex work. For example, the proportion of transgender people who sell sex is estimated to be up to 90% in India, 84% in Malaysia, 81% in Indonesia, 47% in El Salvador and 36% in Cambodia.6

HIV prevalence among transgender sex workers is as high as 32% in Ecuador and Panama compared to just 0.4% and 0.6% respectively among the general population.7 A 2008 systematic review showed that global HIV prevalence among transgender people who engaged in sex work was 27%, compared to 15% among transgender people who did not sell sex.8

Data suggests that HIV prevalence is up to nine times higher for transgender sex workers compared to non-transgender female sex workers.9

Knowledge and reported use of condoms is generally low among transgender sex workers. In Asia and the Pacific, only 50% of transgender sex workers are aware of HIV and HIV testing, and only 50% reported using condoms consistently with clients and casual partners.10

In addition, the high costs associated with transition healthcare can put extra pressure on transgender people to make money.11 Sex workers sometimes get paid more for unprotected sex, and often feel under pressure not to use a condom, which makes them highly vulnerable to HIV.

High-risk sex

There are high rates of unprotected anal sex among transgender women, which carries a high risk of HIV transmission.12 Several factors contribute to this. Stigma and discrimination, leading to low self-esteem and disempowerment, can make it harder for transgender people to insist on condom use.13

In many settings, condom use is often controlled by the insertive sexual partner, so many transgender women who have sex with men can feel unable to instigate condom use.14 Gender-changing hormones, which some transgender women use, can lead to erectile dysfunction, increasing the likelihood of taking the receptive role during sex.15

There are other social factors that make transgender people more likely to engage in high-risk sex. Studies have shown that some transgender people who want to affirm their gender identity through sex, or who fear rejection from sexual partners can be more likely to agree to unprotected sex.16The stress of social isolation may also lead to a much higher rate of drug and alcohol use among transgender people that can affect their judgement of risk and make them less likely to use condoms.

Injecting hormones

It is common for transgender people to obtain injectable hormones, the most common form of gender enhancement, and carry out the injecting themselves.Without counselling on safe injecting practices, people going through this process may be very vulnerable to HIV transmission because of the risk of sharing needles with others.17

Transgender people can have very diverse HIV prevention needs. Targeted prevention approaches that respond to the specific needs of individuals are essential to reducing HIV infections. In addition, prevention initiatives that empower transgender people and enable them to take the lead in meeting the needs of their own community are the most effective.18

Sexual health care for transgender people is often inadequate, with many policy makers and service providers failing to address the needs of transgender women as a population distinct from men who have sex with men.19 Only 39% of countries in 2014 had specific programmes targeting transgender people in their national HIV strategies.20

India is one country where HIV services have been successfully targeted at transgender people – reaching an estimated 83% of the transgender population. They have also made marked steps in officially recognising transgender people, also called Hijras, as a third gender. This means that local authorities need to ensure that they have health and social programmes that meet the needs of Hijras and has given them the right to vote.21

Providing welfare, employment initiatives and housing can help address the factors that make transgender people more likely to engage in high-risk sex.22 Services for other needs should also be provided, such as mental health counselling and support for a sex change operation.

More broadly, policies that affect the lives of transgender people should be gender affirming, aiming to support transgender people to live congruent with their gender identity. Health workers, particularly primary care providers, need sufficient training to understand and respond to the complex health and rights needs of transgender people.

In 2015, the LINKAGES project which works with transgender women as well as men who have sex with men in four high-prevalence provinces of Thailand, introduced a number of innovative approaches to improve HIV testing, care and treatment services.

A social network recruitment process means community-based project workers conduct structured outreach focused on individuals at highest risk. Clients are offered monetary incentives to act as peer mobilisers and asked to recruit and refer their friends and sexual partners for rapid HIV testing at community-led drop-in HIV service centres.

People who test positive are provided with point-of-care CD4 testing and referred for immediate treatment initiation, with ongoing support and follow-up. People who test negative but are at high risk of infection can access free pre-exposure prophylaxis, and are contacted regularly for repeat HIV testing.

A mobile data-collection platform, eCascade, links outreach activities to community-based HIV testing and clinics providing ART. This platform means referrals can be tracked across services in real time, allowing programme staff to respond to client drop-out, adapt outreach approaches to target efforts where they are needed, and follow-up with clients via SMS messaging.

Programme data from the first nine months of implementation in the city of Chiang Mai shows:

In India, national HIV prevalence is 0.31%, whereas HIV prevalence among the transgender community is estimated to be 8.2%.24 A range of social, economic and legal factors contribute to the increased risk of HIV faced by transgender people who are marginalised and often lack access to health and other basic services.

The Pehchan project works with transgender people across 18 Indian states to increase their access to health, social and legal services. Pehchan incorporates true community involvement at all programme stages and works with community-based organisations (CBOs) to empower individuals through gender-affirming activities.

Pehchan undertakes three types of activities:• improving organisational and technical capacity of CBOs working with transgender communities• supporting CBO’s in providing community-based HIV prevention and linking people to medical care and treatment• creating a supportive environment for transgender communities by facilitating access to wider social, legal and health services.

The programme, which began in October 2010, has helped 200 CBOs to provide tailored HIV services to transgender communities. By August 2015 the programme had reached more than 433,000 people, 60% of whom had never been reached by HIV prevention services before.

By involving transgender people at every level, the programme succeeded in targeting these hard to reach communities. Transgender people were recruited as staff across the organisation, the communities were engaged in technical areas alongside experts and a community advisory board was set up to provide ongoing feedback.25

El Salvador is estimated to have over 2,000 transgender people – more than a quarter of whom live in the capital city, San Salvador.26 They are one of the country’s most stigmatised groups, and are regularly subject to human rights violations, including hate crimes.27 Nearly half of the transgender women in San Salvador report that their main income is from selling sex, and HIV prevalence among transgender women in the city is estimated at 16.2% compared to less than 1% among the general population.28

In 2014, El Salvador’s Ministry of Health partnered with NGO, Plan International, to reduce the rate of new HIV infections among transgender people and other key affected populations. Three comprehensive prevention community centres were established. Run by peers, the centres provide basic HIV prevention and healthcare services tailored to the specific needs of transgender people. These include general medical and mental health services, HIV testing and counselling (HTC), as well as information on correct and consistent condom and lubricant use. In addition, mobile teams provide HTC in areas with high numbers of transgender people.29

About one quarter of San Salvador’s transgender population - were reached with a basic HIV prevention package during the first six months of 2015. VICITS have also strengthened the efforts of transgender women in San Salvador to claim recognition as a group distinct from men who have sex with men.30

Generally, data on transgender access to HIV treatment and testing services is scarce. One study of people living with HIV in the United States of America (USA) found that only 59% of transgender participants, compared to 82% of those with a birth-assigned gender, were accessing antiretroviral treatment (ART).31

HIV-related stigma creates barriers to getting tested for many transgender people. In a study in the USA, 73% of transgender women who tested HIV-positive had been unaware of their status.32

As with access to HIV prevention advice, transgender people may delay seeking testing and treatment due to transphobia and insensitivity among healthcare professionals.33

Yes I tested and was not of the best as the person who pricked me urged me to change my life, as I being like I am is immoral, she said.

Depression and isolation are often associated with poor adherence to HIV treatment. A lack of supportive relationships can affect important aspects of living healthily with HIV, such as remembering to take medication. One study found that transgender people living with HIV were less likely to report adherence to treatment of above 90% compared to patients who weren’t transgender.35 The study found that many transgender people found it difficult to take regular medication alongside other treatments such as hormone therapy.

Social exclusion

Transgender people will often experience social exclusion and marginalisation in the society that they live and, critically, from family and friends. In Latin America, between 44% and 70% of transgender woman were either thrown out, or felt the need to leave their homes. In the Philippines, paternal rejection during transitioning of transgender women is reported to be as high as 40%.36

This exclusion can affect people's self-esteem and self-worth, contributing to depression, anxiety, substance abuse and self-harm.37 In a national study of transgender people in the USA, 41% of participants reported attempting suicide, compared with 1•6% of the general population. A national Australian study found that 56% of transgender people had been diagnosed with depression at some point in their lives, four times the rate for the general population. The study found that 38% had been diagnosed with anxiety, around 50% higher than the background rate.38

Lack of social safety nets also make transgender people particularly vulnerable to economic instability and homelessness. A survey from the USA found that unemployment rates for transgender people were twice the national average.39

General isolation and social exclusion affect access to treatment. Transgender people can be afraid to get tested if they don’t have a strong support network to help them cope:

No, I won’t test. Who will take care of me when I test positive? I have no-one.

Lack of recognition of gender identity

Many countries do not legally recognise the gender of transgender people, meaning they often lack official identification, passports and travel rights, welfare entitlements and the right to marry.41 They may also find it difficult to access education and employment. For transgender women facing criminal prosecution, incarceration with male inmates can also put them at risk of sexual assault.42

Healthcare system discrimination

Barriers to accessing ART among HIV-positive transgender people are well-documented.4344

Discrimination from healthcare providers, a lack of knowledge about transgender needs and the refusal of many national health systems or health insurance providers to cover their care all contribute to situations where it is difficult for transgender people to receive adequate treatment. This can also encourage discrimination within healthcare services, making it hard to access sexual health services.

Nine out of ten trans people do not consult doctors even in case of serious illness, because of the mistreatment they know they will face in health services.

Transgender peoples’ access to health care is further complicated by the fact that their experiences have been classified as a mental disorder, meaning they must accept this stigmatised diagnosis when accessing health services. The World Health Organization (WHO) has proposed that references to transgender people in their health diagnosis literature be placed in a chapter called ‘conditions relating to sexual health’ and removed from the list of mental disorders. This has been welcomed by the global transgender community, clinicians and researchers. 46

The criminalisation of same-sex sexual activity, which as of May 2016 was still in place in 73 countries, can also affect transgender people. For example, if a transgender woman is legally recognised as a man because she was assigned male at birth, sex with a birth-assigned man would be illegal. She may risk prosecution if she discusses her own sexual history with a healthcare professional.48

Laws such as these can legitimise acts of stigma, discrimination and violence against individuals.49 This can put transgender people at a greater risk of sexual abuse and violence, and HIV infection.50

In some cases, police shut down organisations that provide HIV prevention services on the basis that these services aid illicit activity such as sex work.51 In addition, most countries do not have laws that will criminalise acts of discrimination towards transgender people.

Violence and transphobia

Violence towards transgender people is widespread and has been increasingly reported.52 Between 2009 and 2016 there were 2,115 documented killings of transgender people worldwide.53 The actual number is likely to be even greater.

Nearly 80% of all killings of transgender people took place in Latin America. In one local transgender community-based organisation in Honduras, Colectivo Unidad Color Rosa, six out of seven members were murdered.54

Many transgender people feel unable to approach law enforcement about the issue. Between 2005 and 2012 in Colombia, 60 transgender women were murdered, and not one person was imprisoned as a result.55 This is compounded by the fact that in many places members of the police often perpetrate violence against this community.

Altogether I have been shot nine times. There are witnesses but they are also afraid to make a statement. I myself have witnessed many other police attacks but I’m also afraid to report them. This is what the police call “social cleansing”. According to them, it’s because there are lots of complaints against transgender women doing sex work.

- Specialist in Public Health and transgender human rights defender in San Pedro Sula, Honduras, July 2012 56

Non-lethal violence against transgender people is also widespread. A national study in the USA found that 35% of five to 18 year olds who identified as transgender experienced physical violence, and 12% were victims of sexual violence. In the same study, 7% of transgender adults had been physically assaulted at work, and 6% sexually assaulted.57

There is a critical lack of data and limited funding for, and research about, transgender people and what drives their vulnerability to HIV.58

More effort is needed by researchers, governments and NGOs to collaborate to find ways to combat HIV among transgender communities – particularly in places where their legal rights are not respected. Initiatives should be developed in partnership with transgender communities, and should link health with advocacy, social justice, and human rights.59

It is vital that transgender people around the world are informed about safer sex and how to protect themselves from HIV, however, until their rights are protected by law and respected by society they will continue to be vulnerable to HIV. Interventions that have focused exclusively on sexual health have not achieved expected results as they failed to address the social exclusion that leads to high-risk behaviours.60

As well as protection by law, transgender people need better access to housing, employment and education if they are not to be driven towards high-risk behaviour.61They must be able to access transgender-specific healthcare services and sexual health information, free from fear of criminalisation and discrimination.

Photo credit: Photo by Gates Foundation/CC BY-NC-ND 2.0. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.